At the HEMS Education Day on 30th May 2018, we had two great presentations on regional anaesthesia from guest speakers Andrew Lansdown and Ananth Kumar.

Ex-Sydney HEMS registrar and current consultant anaesthetist Andrew Lansdown gave us an excellent presentation on regional anaesthesia of the hip, thigh and knee. He has kindly shared his slides below.

Fellow anesthetist Dr Ananth Kumar then covered the Serratus Anterior Plane (SAP) block, perfect for anterior / lateral rib fractures. First described in 2013, this ultrasound-guided approach is simple, safe, and very effective, although its exact mechanism of action is still somewhat mysterious.

Here’s a video of the SAP block being done:

The talks were followed by practical stations, in which the retrieval Sonosite iViz devices were used to identify sonoanatomy in volunteers.

Airway Registry learning points reflect the challenges described and wisdom shared by Sydney HEMS personnel and guests at the Clinical Governance Airway Registry presentation for January 2018. Cases are discussed non-contemporaneously, anonymised and amalgamated over a time period to draw together unifying take-home messages. Details of specific cases are removed and/or changed, such that any similarity to real-life patients or scenarios is coincidental.

Focus on: Soiled Airway

The threat of massive airway soiling at laryngoscopy and intubation has troubled airway practitioners for decades; and yet, in 2018 we still don’t have a great evidence based plan of how to approach such threats.

To view this video you will need this password: AiRblogVideos

Discussion points around this challenge include:

Predictability – in addition to history & examination – could bedside gastric ultrasound assist us with risk assessments when feasible?

Preparation – practising a ‘SALAD’ sim at the base, and talking through your actions in your airway plan with your team before starting

Other Airway soundbites this month

Laryngospasm after Ketamine

Laryngospasm or apnoea occurring after ketamine sedation can be frightening for the practitioner and is one of the reasons why other prehospital services have ketamine sedation ‘protocols’. Symptoms and signs of laryngospasm witnessed by our service following a small sub-dissociative (<0.5mg/kg) dose for agitation were:

Reoxygenating

Reoxygenating between laryngoscopy attempts can be difficult – OPAs, NPAs and two-person-technique for bag mask ventilation is generally recommended but is challenging for those patients sporting a beard. Solutions suggested have included “plasticising” the beard with tegaderm, but this is rarely practical in the Retrieval setting where airway management is rarely elective.

One alternative to reoxygenate between laryngoscopy attempts is to use our iGel SGA which is not affected by the presence (or absence) of facial hair.

CMAC Caution

Our CMAC pocket monitor laryngoscopes have a built-in ability to turn themselves off (blade light and screen). Manufacturer advice is that this will happen after 10 minutes of no use detected by no change in light intensity at the camera. The device turns on again very quickly by closing and opening the screen. Should this occur during a laryngoscopy, it may be prudent to open and close the screen in situ.

Blade Tip Positioning

Laryngoscope blade tip position is critical to successful laryngoscopy. The following still shots from CMAC Pocket Mac 4 blade videolaryngoscopy show this in action.

The first image shows the tip sitting high of the vallecula (where the smooth shiny epiglottis mucosa meets the lumpy bumpy tongue). Efforts to lift the epiglottis by lifting the laryngoscope here are unsuccessful resulting in no view of the larynx (Grade 3 view as epiglottis only seen). The middle image shows the tip sitting in the vallecula where indirect epiglottic lift with the laryngoscope is successful revealing the laryngeal inlet (Grade 1 view = POGO 100%).

Airway Registry learning points reflect the challenges described and wisdom shared by Sydney HEMS personnel and guests at the Clinical Governance Airway Registry presentation for January 2018. Cases are discussed non-contemporaneously, anonymised and amalgamated over a time period to draw together unifying take-home messages. Details of specific cases are removed and/or changed, such that any similarity to real-life patients or scenarios is coincidental.

Focus on: Beach

Some of our work takes us to the beach, particularly during the summer months, although the NSW climate is such that beaches are frequented by residents and tourists year-round.

This month we talked about the specific challenges inherent in undertaking our prehospital work in a beach setting.

The Location

The downwash of the helicopters used in our service can cause issues with sand blasting the patient, caregivers, and bystanders on landing and take off.

Beaches are very public spaces so we may experience reticence from our flight crew towards shut down of the helicopter in beach location (rather than hot offload etc)

Crowd control can be an issue, particularly if we are the first asset on scene. We can expect bystanders and onlookers aplenty encroaching on ‘our space’ and this adds to the mental load of the team

The inherent instability of sandy surfaces creates challenges for moving and positioning the patient & the patient’s airway

Sand is also very ready to swallow our equipment; we should be cautious around placing items on the sand as we may never see them again! This is particularly true of smaller items like syringes or the thoracostomy kit but we should be mindful of the additional challenges of equipment maintenance in these environments

For patients who have been immersed, even if they are out of water by the time of our arrival, we might experience airway flooding with sea water or even pulmonary oedema at laryngoscopy

Solutions from the Sydney HEMS Hive Mind

Consider the possibility of winching to scene – though there may still be significant downwash generated

Clearing the beach whenever possible and using additional resources (Police, road Ambulance crews) to do this

Moving the patient to a solid surface or ideally to an ambulance stretcher for RSI

Laying a surface covering over the sand to create a treatment area for kit dump. Examples we came up with that might be available to us included

Anticipate the need for suction and have two sources of suction (ideally) ready

Other Airway soundbites this month

Ability to confirm tracheal placement of endotracheal tube can hampered by time for waveform ETCO2 to ‘warm up’ on some monitors if not already warmed up-> remember the EMMA capnometer is widely available from NSW Ambulance crews as well as being carried in our blue prehospital pack.

Intubating the acidotic patient – apnoea feeds hypercapnoea and acidosis – hyperventilation is needed to both fight the patients own CO2and that generated by exogenous bicarb administration. Any ventilations during RSI should be done in a way that limits gastric insufflation – we suggest 2 person bag-mask ventilation, limiting inflation pressures and use of a guedel (oropharyngeal) airway.

Inadequate paralysis at RSI – note our new RSI operating procedure recommends a dose of 2mg/kg Rocuronium. This gives an average paralysis time of 2 hours from onset.

Our training and clinical governance processes for RSI include frequent currencies for doctors and paramedics in our service to maintain efficient team working and safety. Only paramedics and doctors within this clinical governance framework can perform laryngoscopy within our service.